Video Loan Request
High School Bioethics Curriculum Project
Kennedy Institute of Ethics

The video lending library is a part of the Kennedy Institute of Ethics’ High School Bioethics Curriculum Project (HSBCP). This program is funded by The Greenwall Foundation and by an anonymous bequest to Georgetown University. The videos may be borrowed by high school teachers, at no cost, for a period of up to two weeks. Arrangements must be made in advance for the use of the video. Any special postage rate, e.g., overnight, two-day air, etc. will be paid by the requesting teacher. The borrowing teacher agrees to assume responsibility for the replacement costs for any tape that is returned in a damaged or unplayable condition and/or for any tape that is not returned by the agreed upon date. The tape must be returned in its original case and with any associated written materials.

Please complete all of the information requested below. Fax the completed form to Laura Bishop, Ph.D., HSBCP Program Director, Kennedy Institute of Ethics at 202-687-8089. Call 202-687-8099 if you have any questions. 

Name:	Email Address:	
Mailing Address:	
Telephone Number:	Fax Number:	

School Name:		
School Address:		
School Telephone Number:	School Fax Number:	

Please indicate whether HSBCP should use  your personal or  your school address with regard to this loan request. 

Video Name:	Inclusive Dates Requested:	
For use in Class Name:	Students in grade: 	

Please provide a brief description of the teaching topic for which you plan to use this video program: 

To be completed by HSBCP and faxed back to the teacher.

Replacement costs for this video program are: __________.  The program is available for your use from __________ to __________.  The video must be returned by _____________ and should be sent insured for the replacement cost.

I agree to permit the Kennedy Institute of Ethics to charge my credit card, a Mastercard  /  Visa (circle one)
___________________________ and __________ in the amount of __________, the replacement cost for
CREDIT CARD NUMBER				EXPIRATION DATE
_______________________________________________ should this video program be returned in a damaged or
VIDEO TITLE
unplayable condition and/or if it is not returned by ______________ unless other arrangements are made with 
							RETURN DATE
Laura Bishop, Ph.D. 202-687-3638.
_____________________________________	_____________________________________
PRINT NAME							SIGN NAME
_____________________________________
DATE